Orthodontic appliances that accommodate incremental and continuous tooth movement, systems and methods

ABSTRACT

An orthodontic appliance including a shell aligner having a portion accommodating movement of a patient&#39;s bracketed teeth between a first position and the second position as elicited by force from an orthodontic braces appliance worn by the patient, related systems and methods.

CROSS-REFERENCE

This application is a continuation of U.S. patent application Ser. No.14/660,375, filed Mar. 17, 2015, which is a continuation of U.S. patentapplication Ser. No. 13/692,891, filed Dec. 3, 2012, now U.S. Pat. No.9,022,781, issued May 5, 2015, which claims the benefit of U.S.Provisional Patent Application No. 61/599,337, filed Feb. 15, 2012, theentire content of each of which are incorporated herein by reference.

BACKGROUND OF THE INVENTION

The present invention relates generally to the field of orthodontics,and more particularly, to dental positioning aligners or appliancesaccommodating incremental tooth movements as well as continuous toothmovements with braces (e.g., bracket and wire orthodontics), as well asrelated methods and systems.

An objective of orthodontics is to move a patient's teeth to positionswhere function and/or aesthetics are optimized. Traditionally, dentaldevices such as braces are applied to a patient's teeth by a treatingpractitioner and the set of braces exerts continual force on the teethand gradually moves them toward their intended positions. Over time andwith a series of clinical visits and adjustments to the braces by thepractitioner, the teeth reach their final destination and the appliancesare removed. These brackets are affixed to the teeth with a bondingadhesive connecting the base of the bracket to the surface of the teeth.

Alternatives to conventional orthodontic treatment with traditionalaffixed appliances (e.g., braces) are now available. For example,systems including a series of preformed appliances/aligners have becomecommercially available from Align Technology, Inc., San Jose, Calif.,under the tradename Invisalign® System. The Invisalign® System isdescribed in numerous patents and patent applications assigned to AlignTechnology, Inc. including, for example in U.S. Pat. Nos. 6,450,807, and5,975,893, as well as on the company's website, which is accessible onthe World Wide Web (see, e.g., the URL “invisalign.com”). TheInvisalign® System includes designing and/or fabricating multiple, andsometimes all, of the aligners to be worn by the patient before thealigners are delivered to the patient and used to reposition the teeth(i.e., prior to the onset of treatment). Often, designing and planning acustomized treatment for a patient makes use of computer-based3-dimensional planning/design tools, such as proprietary Treat™ andToothShaper™ developed and used by Align Technology, Inc. Aligner designcan be based on computer modeling of a series of planned successivetooth arrangements, and the individual aligners are designed to be wornover the teeth and elastically reposition the teeth to each of theplanned tooth arrangements.

While recently developed orthodontic treatment technologies such asthose described above represent a considerable advancement in the fieldof orthodontics, additional advancements remain of interest. Even thoughInvisalign® aligners can be used for a wide range of orthodontictreatment, in some instances orthodontic treatment making use of acombination of both traditional affixed (e.g., bracket/wire) appliancesand shell-type aligners may be desired by a treating professional basedon the individual needs/desires of the patient. As such, there is a needfor innovative products that provide an orthodontic patient withtreatment which includes both traditional affixed (e.g., bracket/wire)appliances and shell-type aligners.

BRIEF SUMMARY OF THE INVENTION

The present invention includes structures and related methods providinga combined use of both traditional bracket/wire devices and shell-typeappliances or aligners.

For a fuller understanding of the nature and advantages of the presentinvention, reference should be made to the ensuing detailed descriptionand accompanying drawings. Other aspects, objects and advantages of theinvention will be apparent from the drawings and detailed descriptionthat follows.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 illustrates an appliance including a braces relief portion and acorresponding jaw of a patient, according to an embodiment of thepresent invention.

FIG. 2A through 2C illustrate tooth movement between an initial positionand subsequent positions (FIG. 2A); tooth and bracket location inillustrated positions; and an aligner relief portion accommodatingbracketed tooth movement between illustrated positions.

FIG. 3 illustrates a method according to an embodiment of the presentinvention.

FIGS. 4A through 4D illustrate aligners including a tooth receivingcavity and braces relief portion according to embodiments of the presentinvention.

FIGS. 5A through 5D show aligners including a tooth receiving cavity andbraces relief portion according to embodiments of the present invention.

FIGS. 6A and 6B conceptually illustrates building an aligner restrictingtooth extrusion but allowing tooth rotation, according to an embodimentof the present invention.

FIGS. 7A through 7D illustrate tooth movement and building an alignerrestricting tooth extrusion but allowing tooth translation, according toan embodiment of the present invention.

FIGS. 8A and 8B show a staged tooth movement and a corresponding portionof an aligner shaped to accommodate the staged movement and apply force,according to an embodiment of the present invention.

FIG. 9 shows non-linear movement of a tooth, according to an embodimentof the present invention.

FIGS. 10A through 10C show positioning and selection of brackets andwires, according to an embodiment of the present invention.

FIGS. 11A through 11C show positioning and selection of brackets andwires, according to an embodiment of the present invention.

FIG. 12 shows an aligner shaped to accommodate a retention wirestructure on a section of a patient's teeth.

FIGS. 13A and 13B illustrate teeth (FIG. 13A) and teeth and acorresponding aligner (FIG. 13B), according to an embodiment of thepresent invention.

FIG. 14 illustrates a treatment line showing a plurality of phases oforthodontic treatment and a plurality of swept tooth paths, according toan embodiment of the present invention.

DETAILED DESCRIPTION OF THE INVENTION

The present invention includes structures and related methods providingcombination or dual treatments that use both traditional bracket andwire orthodontics/braces, as well as more newly-developed shell-typeappliances or aligners.

A discussion of shell-type appliances or aligners provides anappropriate starting point in a discussion of the present invention withrespect to tooth repositioning appliances designed to accommodate a wireand bracket system for a combined shell appliance and wire/bracketsystem for repositioning teeth. A tooth repositioning shell-typeappliance can be worn by a patient in order to achieve an incrementalrepositioning of individual teeth in the jaw. The appliance can includea shell (e.g., polymeric shell) having teeth-receiving cavities thatreceive and resiliently reposition the teeth. In one embodiment, apolymeric appliance can be formed from a known thin sheet of suitableelastomeric polymeric material, such a 0.03 inch thermoformable dentalmaterial by Tru-Tain Plastics, Rochester, Minn. An appliance can fitover all teeth present in an upper or lower arch, or over less than allof the teeth. In some cases, only certain teeth received by an appliancewill be repositioned by the appliance (e.g., certain teeth covered bythe appliance will receive orthodontic forces) while other teeth canprovide a support or anchor region for holding the appliance in place asthe other portions of the appliance apply force against the tooth orteeth targeted for repositioning. In some cases, many or most, and evenall, of the teeth will be repositioned at some point during treatmentdepending on the aligner configuration at the time. Teeth that are movedat one point during treatment (e.g., moved teeth) can also serve as asupport or anchor for holding the appliance and vice versa, throughoutthe course of the appliances being worn by the patient. In a series ofappliances, some appliances may engage the teeth without the need forsupplemental assistance for appliance retention, but in some cases, itmay be desirable or necessary to provide individual anchors bonded onthe teeth with corresponding receptacles or pockets in the appliance sothat the appliance can apply a specific force on the tooth. Exemplaryappliances, including those utilized in the Invisalign® System, aredescribed in numerous patents and patent applications assigned to AlignTechnology, Inc. including, for example in U.S. Pat. Nos. 6,450,807, and5,975,893, as well as on the company's website, which is accessible onthe World Wide Web (see, e.g., the URL “www.invisalign.com”).

An appliance can be designed and/or provided as part of a set orplurality of appliances. In such an embodiment, each appliance may beconfigured so a tooth-receiving cavity has a geometry corresponding toan intermediate or final tooth arrangement intended for the appliance.The patient's teeth can be progressively repositioned from an initialtooth arrangement to a target tooth arrangement by placing a series ofincremental position adjustment appliances over the patient's teeth. Atarget tooth arrangement can be a planned final tooth arrangementselected for the patient's teeth at the end of all planned orthodontictreatment. Alternatively, a target arrangement can be one of manyintermediate arrangements for the patient's teeth during the course oforthodontic treatment, which may include where dental surgery isprescribed (e.g. tooth extractions), where interproximal reduction (IPR)or tooth reshaping for the creation of space is needed, when a progresscheck is needed, where spaces are needed for post-orthodontic dentalrestorations, where anchor placement on the tooth surface is optimal,where the aligner trim line should be located, etc. As such, it isunderstood that a target tooth arrangement can be any planned resultingarrangement for the patient's teeth that follows one or more incrementalrepositioning stages. Likewise, an initial tooth arrangement can be anyinitial arrangement for the patient's teeth that is followed by one ormore incremental repositioning stages. The aligner appliances can begenerated all at the same time or in sets or batches. The patient wearseach appliance for a fixed length of time as instructed by theirprescribing doctor, typically 20-22 hours a day, and from 10-21 days foreach appliance. A plurality of a series of different appliances, witheach upper and lower jaw pair being a “set” in the series, can bedesigned and fabricated prior to the patient wearing any appliance ofthe series. After wearing an appliance in the set for an appropriateperiod of time, the patient replaces the current appliance(s) with thenext appliance(s) in the series until the appliances in the series havebeen worn. Additional series of appliances may be fabricated and wornuntil a satisfactory treatment outcome is achieved. Unlike orthodonticbrackets which are directly bonded to the teeth, the aligner appliancescan be removed by the patient throughout the treatment process (e.g.,during eating, brushing, etc.).

Bonded orthodontic braces move the teeth as a result of orthodonticforce (pressure) delivered to the teeth via an orthodontic wire which isconnected to the brackets. The wire is elastically deformed when it istied to the braces, and as the wire tries to return back to its originalshape, the teeth which are connected to the wire are pushed or pulled bythe wire as it reconfigures itself from the distorted position back toits relaxed position. Sometimes springs or rubber bands are used to putforce in a more specific direction. For example, springs placed on anarchwire can help push apart or bring together teeth along the archwire.Rubber bands can help coordinate the upper and lower jaw by pullingteeth in one jaw against teeth in the other jaw. Fixed braces tend toapply a more continuous pressure whereas aligners apply incremental orinterrupted forces because of their removable nature.

Some embodiments of the present invention includes one or moreshell-type aligners or appliances that accommodate braces (brackets andwire(s)) positioned on the patient's teeth to allow for simultaneoustreatment with braces and shell-type aligners. Such appliances willtypically engage certain teeth so as to apply a repositioning force tothose teeth, as well as accommodate teeth to have braces (brackets andwire(s)) coupled simultaneously therewith. Systems and methods describedherein can include a single aligner or a plurality or series ofaligners—e.g., a plurality of aligners designed to be sequentially wornby a patient.

FIG. 1 illustrates an appliance that accommodates braces positioned onthe patient's teeth. A jaw of the patient is shown having braces bondedto several teeth. The tooth repositioning appliance can include anappliance as described above and further modified or configured toaccommodate the braces positioned on the patient's teeth. The appliancecan be worn by the patient in order to achieve incremental positioningof individual teeth in the jaw. The appliance includes a shell havingteeth-receiving cavities that receive teeth and apply a resilient forceto one or more of the teeth received. The appliance shell furtherincludes a braces or bracket receiving portion that accommodates thepositioned braces. Accommodation can be defined as cutouts in thealigner which border around the braces or component thereof (e.g.,bracket, wire, etc.), or a covering (partial or full) over the braces orcomponent in such a way that the aligner can be placed and removedwithout dislodging the brackets. As described further herein, the bracesor bracket receiving portion of the appliance will typically include amovement path volume or geometry configured to receive the braces andaccommodate a certain range of movement of the bracketed teeth duringorthodontic treatment or a particular phase thereof.

As used herein, the term “braces” generally refers to one or morecomponents of a bonded orthodontic braces appliance configured to retainor move teeth as a result of orthodontic force(s) delivered to bracketspositioned on the patient's teeth. A braces component can includebracket(s), wire(s), elastic(s), ligature(s) and the like. A reliefportion (e.g., braces or bracket relief portion) of an appliance can beconfigured to accommodate one or more components of an orthodonticbraces appliance, e.g., as described further herein. A bracketed tooth,as used herein, refers to a tooth of the patient having a bracket orbraces appliance positioned therein. Thus, a bracketed tooth may includea positioned bracket only, or a positioned bracket and one or moreadditional components of a braces appliance.

One attempt to accommodate bracketed teeth in a shell type aligner mayinclude aligners manually trimmed by the doctor to remove alignermaterial that might otherwise cover the brackets and/or tooth areaswhere the brackets and wires are positioned or to be positioned.Problems typically arise with such an approach, however, due to a lackof sufficient coordination between the aligners delivering fixedincrements of tooth movement, and the braces delivering continuous,undefined movements. As a result, a problem of aligner fit can become anissue as a result of the asynchronous coordination between the expectedtooth movement built into the aligners and the actual tooth movementaccomplished by the braces. In other words, the braces may not move theteeth sufficiently to the next pre-defined increment defined within thealigner shell by the time the patient changes the aligners, or if thebraces move the teeth beyond the pre-defined increment by the time ofthe next aligner change. Such decoupling between the movement elicitedby the aligner and the movement elicited by the braces can result in anon-fitting or ineffective shell appliance that no longer works for thepatient. Cutting away of aligner material can also weaken the alignerstructure, and may minimize or eliminate the desired effect on thetooth/teeth to be moved.

A challenge, therefore, is to create a system that allows forincremental (e.g., pre-programmed aligner-elicited movement) as well ascontinuous (e.g., braces elicited movement) tooth movements concurrentlyor simultaneously. One approach is to plan or predict the movements fromboth system components and design aligners precisely to fit and delivertooth movement at identified stages or phases of treatment based onknown biological tooth movement rates published in the scientificliterature. For example, one may try to predict the rate of toothmovement that can be achieved with different bracket and wire systems.Since the rate of tooth movement with braces depends on a number ofvariables, including but not limited to the type of wire material used(e.g. stainless steel vs. nickel titanium), the size of the wire used(e.g. 0.014 inch, 0.018 inch), the shape of wire used (square vs.round), the age of the patient, the gender of the patient, the size ofthe tooth root, the bone level around the tooth, the type of bone(maxillary or mandibular; maxillary has better blood circulation), andwhether certain medications may be taken prior to and/or duringtreatment (e.g., anti-inflammatory drugs, bisphosphonates).

Another approach includes identifying a movement scenario that buildsinto an aligner a space or relief that accommodates a fixed increment oftooth movement with or without a margin for deviation. For example, analigner may be built so as to accommodate an increment of movement thatexceeds the most likely scenario of tooth movement for the bracesportion (which could be based on rates published in the scientificliterature for example), and including an additional space that allowscertain teeth (the bracketed teeth) to freely move from the currentpositions to the maximum likely tooth movement positions. This preventsthe aligners from interfering with the tooth movement and prevents theteeth with the braces from preventing aligner seating. The most extremeversion of this approach would be to accommodate the bracketed teethfrom the beginning position all the way to the end position. In thisextreme scenario however, the aligner portion covering the bracketedteeth may be loose and uncomfortable for the patient, especially if thedistance for the tooth to travel is large. Furthermore, an even greaterdeviation may be needed as an accommodation if the actual path of thetooth requires a non-linear deviation from the beginning to endposition. For this reason, and also to accommodate such non-linear pathsof teeth and/or different tooth movement timing sequences (e.g., caninesbeing retracted first, then the anterior teeth later), having a limitedrange of possible movements from the current position is a betteralternative than encompassing the entire planned path for each toothbeing bracketed.

In one embodiment, the braces portion of the aligner (the part whichaccommodates the teeth with the braces bonded to them) can include atooth movement path volume or geometry determined based on identified orpredicted movement of a tooth or teeth between two or more positions.Identifying a tooth movement path and the corresponding volume orgeometry of a bracketed tooth moving along the path digitally or bycomputer, and designing a corresponding aligner to accommodate themovement path volume or geometry is illustrated with reference to FIGS.2A-2C. One or more of various types of tooth movements may beaccomplished, including but not limited to, inclination, angulation,translation, rotation, intrusion, extrusion, or combinations thereof andeliciting a tooth movement. The present invention will not be limited toany particular movement or movement type. For illustrative purposes,FIG. 2A diagrams a simplified tooth movement (translation) betweenpositions P₁, P₂, and P₃. FIG. 2A shows a tooth at position P₁ withdashed lines providing a reference point for tooth and bracketpositioning at the “initial position.” As the tooth moves to P₂, boththe tooth and the bracket are shifted right relative to the initialtooth and bracket positions as in P₁. Further movement of the tooth toP₃ further shifts tooth and bracket positioning relative to the initialposition of the tooth and bracket. FIG. 2B shows tooth and bracketpositions at P₁ through P₃ overlaid to illustrate the movement pathvolume or geometry (the geometric summation of the incremental toothmovement as the increment of movement approaches zero from initial totarget position) of the tooth with its bonded bracket. The movement pathmay include and be defined by a plurality of staged tooth positions asdescribed, and may further include interpolation of tooth positionsbetween particular identified or digitally represented tooth stages orpositions. FIG. 2C illustrates an aligner portion having a movement pathvolume or geometry based on predicted or computed movement of the toothand bracket between P₁ through P₃. The aligner includes a toothreceiving cavity having a volume and geometry shaped to accommodate apath of movement of the tooth between P₁ through P₃. The aligner furtherincludes a relief portion, e.g., braces-receiving relief portion, havinga volume and geometry shaped to accommodate a path of movement of thebracketed tooth between P₁ through P₃.

FIG. 3 is a flowchart illustrating steps of a method, such as acomputer-implemented method, for providing an aligner accommodating abraces-elicited movement of one or more bracketed teeth. A methodincludes determining a first position of a bracketed tooth. Next, is adetermination of a second position of the bracketed tooth. Thereafter,the movement path from the first position to the second position isdetermined or calculated. Next, a movement path volume or geometry isdetermined based on the first and second positions and the movement pathof the bracketed tooth. An appliance is designed and/or fabricatedincluding a portion or relief in the appliance cavity configured with avolume or geometry to accommodate movement of the bracketed toothaccording to the calculated movement.

As discussed above, various aligner shapes and/or designs can beselected for use in a combined aligner and braces system as describedherein, and aligners will not necessarily be limited to any particularshape, geometry or design. As discussed above, an aligner can include areceiving portion or relief shaped to accommodate positioned bracket orbraces. Various suitable shapes and/or designs can be accomplishedaccording to the systems and methods described herein. Certainnon-limiting examples of aligner shapes or designs are provided withreference to FIGS. 4A through 4D. FIG. 4A shows a cross-section view ofan example aligner portion shaped to accommodate braces/bracketed teeth,where the aligner wall extends outward laterally from the bracketedtooth surfaces to form a relief portion. FIG. 4B is another example ofan aligner portion shaped to accommodate braces/bracketed teeth, wherethe aligner wall extends outward to form a non-uniformly shaped reliefportion.

An aligner or relief portion thereof can be shaped or designed tofacilitate placement of the aligner on the patient's teeth (bracketedteeth), while minimizing unwanted contact between the aligner andbraces. For example, the aligner relief portion may be shaped tominimize contact between the aligner and braces that might makeplacement of the aligner over teeth difficult or potentially damaging tothe aligner and/or braces structure. FIG. 4C shows a cross-section sideview of an aligner positioned over a tooth having a bracket attached.The side of the aligner extending over the bracket has a shortened sidewall that extends less than the entire distance of the tooth crownportion, or less than the entire distance between the occlusal portionof the tooth and gingival line or edge. FIG. 4D is a side view showingan aligner positioned over a bracketed tooth, where the relief portionhaving a distal portion or portion extending in a gingival direction andflared laterally so as to minimize an edge of the aligner catching orbutting against the bracket during aligner insertion and removal.

The aligner or relief portion thereof can include various shapes ordesigns, and may include, for example, a protrusion, bubble, envelope,slot shape and the like. The relief portion may be defined by acontinuous or substantially continuous portion of the aligner ormaterial, or may be composed at least partially or wholly of one or morematerials different from material(s) forming other parts of the aligner.In some instances, a relief portion may form an open portion, so as toform a hole, window, annulus, and the like. A relief portion may includeor define an insertion path (e.g., a passive insertion path) to receivethe braces/bracketed tooth so the aligner avoids contacting or clippingthe attachment structure (e.g., bracket, wire, elastic, elastic chain,springs, etc.). Thus, as discussed further herein, the relief portioncan be designed to reduce or minimize unwanted contact that mightdisrupt or damage the bracket positioned on a tooth, or otherwisedisrupting a braces component.

Further non-limiting examples of aligner shapes or designs are providedwith reference to FIGS. 5A through 5D. Each of the illustrated examplesshow an aligner having a tooth receiving cavity and a braces reliefportion, the cavity and relief having a structure or geometry shaped toaccommodate movement of a braces/bracketed tooth along a movement pathas described herein. FIG. 5A shows an aligner having a tooth receivingcavity with a relief portion, where the relief portion includes aportion of the aligner that is open to the braces, e.g., forming acut-out or cut-away, such that the braces are not substantially receivedwithin the cavity or relief portion. FIG. 5B shows an aligner having atooth receiving cavity and a relief portion that at least partiallyreceives the bracket/braces as the aligner is positioned on thepatient's teeth. The relief potion forms a bubble or envelope thatextends out laterally relative to the adjacent portions of the aligneror adjacent surface of a tooth received in the aligner cavity. As shown,the relief portion is shaped such that the bracket is at least partiallydisposed within the relief portion, and the wire remains at leastpartially outside the relief portion. FIG. 5C shows an aligner having atooth receiving cavity and a relief portion, where the relief portiondefines an envelope or channel shaped to accommodate a received bracketand wire. The envelope extends both laterally and vertically (i.e.,along a long axis of the tooth). The envelope can include a portion thatextends or protrudes further outward compared to an adjacent portion ofthe envelope, so as to more easily receive and accommodate bracketpositioning as the aligner is positioned or removed from the patient'steeth. FIG. 5D shows an aligner having a tooth receiving cavity and arelief portion, where the relief portion defines an envelope or channelshaped to accommodate a received bracket and wire positioned moregingivally on the tooth.

Various types of movements and positioning of the teeth may beaccommodated according to the methods and techniques described herein.Movement between two or more positions can include initial,intermediate, and/or final position of the teeth per overall treatmentor a phase of treatment. In one embodiment, the braces-receiving reliefportion of the aligner between an initial position to a target positionincludes an intermediate position before reaching the final desired goalposition. The defined path of the tooth and its bracket do not need tofollow a linear path. See, e.g., FIG. 9.

In another embodiment, the braces accommodating or relief portion of analigner includes a movement path volume or geometry which accommodates aselected range of tooth movement (e.g., maximum possible tooth movement)in a selected increment of time that the aligner is to be worn. Forexample, if teeth would not be reasonably expected or predicted to movemore than 1 mm in one month, than a +1 mm envelope of movementprogrammed into an aligner that is to be worn for 2 weeks wouldadequately contain enough space for the teeth with the braces to movefreely.

In another embodiment, the braces accommodating or relief portion of analigner includes a shape, or volume or geometry, which accommodates aselected range of tooth movement, where the range of movement is basedon an identified or predicted movement further including a sort of“error margin” or buffer distance for less movement and greater movementthan that identified or predicted. For example, the braces portioncontains movement ahead as well as behind according to a fixed interval(the increment itself does not necessarily have to be symmetric, meaningthe forward increment can be greater than the backward increment or viceversa), to account for the possibility that the teeth with the bracesmight not be caught up to expected positioning, as well as to accountfor the possibility that some or all of the bracketed teeth may movemore rapidly than expected at any particular stage. In other words, ifthe teeth are at a position time point T, then the braces portion mightbe T+X and T−X if the increment of cushion is the same, or T+X and T−Yif the buffer increment are not the same (e.g. a buffer of 4 weeks ofanticipated movement forward, and the position of the teeth 2 weeksprior to the anticipated target). A potential advantage of the forward(and “backward”)-looking fixed increment of time (or correspondingmovement) is that variants in staging pattern such as canine-retractionfirst and non-simultaneous selective movements can be built into thetreatment plan without creating a large bubble in the aligner, which maybe the case if the entire path from before to after is built into thesectional region for the braces. By not creating a large bubble, thealigner is better retained to the teeth and the chance of tissueirritation from the cheeks and lips being trapped underneath the aligneris reduced.

In another embodiment, an aligner braces/bracket relief portion may beconfigured such that certain directions of tooth movement are enabledwhereas certain directions are restricted. For example, the verticalposition of the teeth (extrusion) may be restricted to prevent the teethfrom erupting early in the treatment, whereas the rotations andtranslations may be unrestricted. This allows certain types of movementsto be restrained from taking place for the purpose of better dimensionalcontrol and the reduction of undesired side-effects, such as withvertical extrusion of molars for example. An aligner may be configuredsuch that a relief portion accommodates or restricts a particular rangeof movement within a given direction or movement vector. See, e.g.,FIGS. 6 and 7.

An aligner as described herein can be configured such that a target orfinal position of a tooth accommodated by an aligner's braces/bracketrelief portion or section reflects tooth movement or an end point thatthe braces with the wire will accomplish. In a braces-elicited toothmovement, the tooth position is governed by the position of the braceson the teeth as well as the prescription built into the bracket, whichthe wire will move the teeth to as the wire straightens out from theinitial active “bent” position when the wire is engaged in the bracketsto the relaxed or passive position. Therefore, setting up the targetposition of the teeth with the likely position of the teeth given theprescription of the brackets may be important to the accuracy of the fitof the aligner throughout treatment. During the setup process, asimulation of the actual bracket and intended final wire arch form maybe used to establish the goal or target position of the teeth to whichbrackets will be bonded. Otherwise the wire will move the teeth with thebrackets towards a goal programmed into the bracket, but the alignersmay try to move the teeth towards a different goal, and this mismatchwill either lead to a poor fit of the teeth with the aligner, or theteeth will be constantly jiggled back and forth between the twopositions when the aligners are taken on and off, and the braces arefree of the aligner constraints while the aligners are not being worn.

The number of brackets positioned on teeth and/or accommodated by analigner as described herein can vary and is not limited to anyparticular number of brackets and wires. As the minimum number ofbrackets that can be connected by a section of arch wire is two bracketsin an arch, aligners as described herein will typically accommodate twoor more brackets. Brackets can be positioned through various manners,including manually or digitally, and directly or indirectly, using anynumber of bracket-positioning systems.

A process or mechanism for bonding the brackets can be any number oftechniques or technologies, including but not limited to indirectbonding trays where brackets are included (e.g. Cadent iQ), placementjigs (e.g. Insignia, Incognito lingual), and/or bracket placement guides(Align's bracket positioning template). Orthodontic bracket positioningmay make use of one or more bracket positioning templates, includingtemplates such as those described, e.g., in U.S. Pat. No. 7,658,610.

Techniques may be employed to ensure that the final position of theteeth built into the aligner is based on the position of the teeth thatthe bracket will move the teeth to when the wire is fully expressed. Fora section or span of teeth (i.e., two or more teeth adjacent to eachother), the position of the teeth relative to each other is important,and may be more relevant compared to the absolute position of thesection relative to the jaw. This is because the braces section onlyaligns the teeth with the brackets relative to each other. The entireunit of the sectional fixed appliances will be positioned relative tothe teeth being moved by the aligners, based on the orientation of thebraces section relative to the non-bracketed section in the aligner.

As will be recognized, aligners as described herein can include variousgeometries or configurations can be selected or designed for use asdisclosed. Aligners can be shaped or designed to accommodate one or moreof the following functionalities: retention of tooth/teeth positioning,prevention of a particular movement or movement type of a tooth;enhancement of movement or force applied to a tooth/teeth due to bracketplacement and wearing braces (i.e., the aligner can assist in themovement of the bracketed teeth rather than be passive in those regionsof the appliance); facilitating guidance of a tooth or teeth along aparticular tooth movement path; protection of certain tissues (e.g.,tongue, cheeks, lips) from bracket contact or irritation.

For example, in some instances, the doctor may prescribe that movementof one or more teeth is not desired during treatment or during aparticular phase of treatment. An aligner of the present invention canbe selected or designed such that the corresponding tooth receivingcavity of the aligner is shaped to facilitate retention of the tooth ina particular position in order to maintain the current position of thetooth. One example is where a tooth or teeth are utilized as an anchorposition, either bracketed or unbracketed, so as to facilitate theapplication of a movement force to the other teeth of the patient'sdentition. Such an aligner can be shaped to facilitate retention of theanchor tooth/teeth in the desired position during treatment. In anotherexample, a particular tooth or teeth may have been moved at an earlierstage of treatment and it is desired that said teeth be held ormaintained in their current positions. An aligner can be shaped ordesigned to facilitate retention of the tooth in the current or targetpositioning while additional orthodontic treatment (e.g., furthermovement) takes place either simultaneously or sequentially (e.g.,movement primarily by braces then aligners then braces, or movementprimarily by aligners then braces).

In another example, and in furtherance of discussion herein, an alignercan be shaped or designed so as to facilitate prevention of toothmovement in a particular manner and/or to guide tooth movement in adesired direction or path of movement. An aligner or portion thereofdesignated as a relief portion can be configured such that certainmovement vectors or paths (including non-linear ones) of movement areenabled whereas certain movements are restricted. In this manner,aligners can be designed or selected so as to enable better dimensionalcontrol or “fine-tuned” movement of teeth with treatment.

FIG. 6 illustrates restriction of posterior tooth extrusion but allowingtooth rotation as an example of aligner design where certain movementvectors or paths of movement are enabled whereas certain movements arerestricted. FIG. 6A illustrates a tooth where the desired movement isillustrated with the curved arrow showing a desired rotational movement,and a vertical arrow showing the desired restriction of movement along avertical movement vector or path (e.g., restrict or prevent extrusionmovement of the tooth). FIG. 6B shows conceptual design and shaping ofan aligner crown portion. A 2D cross-section of a crown portion of atooth is shown. As the tooth is moved from a first position tosubsequent positions to accommodate the rotational movement,corresponding staged 2D cross-sections are superimposed to illustrate atooth movement path as the tooth rotates. The staged 2D cross-sectionsdefine a tooth movement path where tooth rotation is permitted, butlateral extrusion movement of the tooth is restricted or blocked by thecrown portion of the aligner cavity. In computer aided design, suchmovement can be enabled by filtering certain directional vectors in acomputer-implemented treatment planning or staging program.

FIG. 7A through 7D illustrates restriction of upper anterior extrusionwhile allowing for translation, e.g., for space closure, as anotherexample of aligner design where certain movement vectors or paths ofmovement are enabled whereas certain movements are restricted. FIG. 7Ashows teeth received in an aligner where translation movement is desiredfor space closure. FIG. 7B illustrates undesired anterior extrusion thatmight result from force application to the tooth crowns withoutrestriction of the vertical movement component. As a force is appliedlaterally to the tooth, the applied force may elicit tooth translationbut also may elicit tipping or rotation around a center of rotation ofthe tooth with an extrusion or vertical movement component. FIG. 7Cshows 2D cross-sections of aligner crown portions for a series ofmovement stages to illustrate a movement path, and further illustratesremoval of intermediate stages such that the aligner crown portion isshaped to accommodate the movement path of the tooth. The crown portionis shaped to allow movement of the teeth along the movement path whilerestricting vertical movement so as to restrict tooth extrusion. FIG. 7Dshows teeth having braces, where the teeth are positioned in an alignerhaving a cavity shaped to accommodate movement of the teeth along atranslation movement path allowing for space closure. As movement forcesare applied to the teeth, the aligner cavity accommodates translationalmovement while restricting tooth extrusion.

In yet another embodiment, an aligner or portion thereof can be designedor shaped to work in conjunction with braces-elicited movement such thatthe movement force(s) applied to the teeth via braces are facilitated orfurther enhanced. In one example, a movement is elicited to a tooth (orplurality of teeth) that is the net result of action by both an alignerand braces. This may occur where both the aligner and the braces impartmovement forces to the tooth, with the system of forces combined toelicit a particular movement to the tooth. In another example, one ofthe braces or the aligner may contact the tooth and act as a leveragepoint or point of resistance to the tooth that affects the movementforce applied by the other orthodontic component. With such dual use,treatment may be enhanced so as to allow improved movements (e.g.,better translation, reduced tipping, etc.) than might be accomplishedusing braces alone. Treatment time may also be shorter because in someinstances, for example, the teeth surfaces may only be accessible formovement to be accomplished by one mechanism (aligners) but not theother (brackets, in the case of severe rotation or deep bite). See,e.g., FIG. 13.

FIGS. 8A and 8B show a staged tooth movement and a corresponding portionof an aligner shaped to accommodate the staged movement and additionallyapply a force to the tooth in conjunction with worn braces. FIG. 8Ashows staged tooth movements between sequential positions (e.g., P₁through P₄)—for example, a first position (e.g., start position) and asubsequent position (e.g., target position), with intermediate positionsthere between. FIG. 8B shows an aligner with a cavity portion positionedrelative to the tooth in the first position of FIG. 8A. The alignerincludes a tooth-receiving cavity portion that is shaped to at leastpartially accommodate the tooth movement path geometry or volume. Thetooth-receiving cavity further incudes a relief portion, which may beshaped to accommodate movement of the braces throughout the entire toothmovement, e.g., as shown in FIG. 8A. The aligner cavity portion isshaped so as to apply a resilient force to the tooth during only aportion of the movement path. For example, when the aligner ispositioned over the patient's teeth, the aligner may stretch toaccommodate the tooth in the first position, thereby applying aresilient force due to elastic deformation of the aligner material. Thealigner cavity includes an active portion that contacts the tooth forapplication of the movement force applied by the aligner. The alignermay be shaped such that the aligner reaches a non-deformed or relaxedstate as the tooth reaches an intermediate position but prior to thetooth moving to the target position. Furthermore, the geometry of thetooth receiving cavity may be selected or shaped to guide tooth movementalong the defined movement path and/or restrict one or movements ordirections of the tooth.

A tooth movement may include moving a tooth linearally or non-linearllyalong a tooth movement path. Referring to FIG. 9, a non-linear movementpath, e.g., to enhance the applied force in the mesio-cervical area isshown. Braces may be applied to the teeth such that more of a crownmovement force might be elicited with braces alone. An aligner can beconfigured to further or additionally apply a root-moving force to thetooth and for application to the teeth in conjunction with the braces.The combination of the braces and the aligner, in such an instance, canbe selected to provide a desired net movement (crown+root) to the tooth.

Designing a system for combined aligner and braces movement forcesapplied to the tooth may have the advantage of allowing a selection ofbrackets (e.g., bracket shapes, types, materials, ancillaries includinghooks, brands, designs, etc., including banding) or bracketlocation/positioning on a tooth that might not otherwise be selected oravailable to a treating professional for delivery of the same toothmovement when only fixed braces alone are used. With regard to bracketpositioning, for example, when using braces alone for treatment, abracket is typically positioned on a tooth in a conventional manner at aprescribed position on the tooth (usually a middle crown point or the FApoint if on the facial surface) to allow maximum accuracy and efficiencywhen eliciting the desired movement. Thus, alternate positioning isgenerally unavailable, thereby restricting the types of movements thatmight be accomplished, when using braces alone. When using a combinedaligner and braces system, a different positioning of the bracket mightbe selected (e.g., bracket moved more toward the occlusal or gingivaldirection). A different type of bracket may also be selected (e.g., amore narrow bracket design) if a portion of the movement is planned tobe accomplished through the aligner and not entirely by the wire. In oneexample, the positioning of one or more brackets might be modified so asto position the brackets lower on the tooth (or more gingivally), suchthat the braces are less visible or allow for improved aesthetics or inorder to avoid the opposing teeth in the case of a deep bite, forimproved comfort for the patient by positioning the bracket away fromsensitive areas, for improved force or torque (e.g, rotational ortipping force), or otherwise accommodating a treatment preference of thepractitioner or the patient. In another example, bracket positioning maybe altered to accommodate combined aligner/braces treatment so as toallow for improved or altered tooth movements as described above.

FIGS. 10A through 10C shown positioning of brackets and wires, as wellselecting alternate bracket positioning and bracket type/design, for usein combined aligner and braces systems and methods described herein. Theposition of the bracket on the tooth affects the position of the wire,and therefore affects the movement force applied to the tooth by thebraces. Different movement forces and/or positioning of braces can beutilized when using a combination of current aligners and bracescompared to use of braces alone. FIG. 10A shows bracket positioning on atooth so as to accommodate normal facial axis (FA) point insertionposition for a straight wire. FIG. 10B shows a modified position of thebracket on the tooth selected to accommodate use of a combined alignerand braces system. The bracket positioning shown in FIG. 10B is at ahigher angle of insertion compared to positioning shown in FIG. 10A, andwire insertion is no longer the normal straight wire insertion. Suchbracket positioning and wire insertion introduces different movementforces to the tooth (e.g., greater lingual inclination forces on theupper incisors than if inserted parallel to the occlusal plane), and analigner can be designed to function in conjunction with such forces soas to elicit a desired tooth movement. FIG. 10C shows selection of alower profile or wire clip type bracket with no inclination (i.e., abracket that allows rotation and inclination dimension movement and alltranslations). The aligner includes a tooth-receiving cavity shaped suchthat the aligner edge is disposed either around or over at least someportion of the bracket to accommodate the bonded bracket while thealigner is being worn. Use of a combined aligner and braces system asdescribed may further allow selection and use of different wires, suchas round wire with a low profile bracket, where the aligner componentreduces the minimum necessary force component required from braces inthe orthodontic system.

Similarly, FIGS. 11A through 11C shown positioning of brackets on atooth, including selecting alternate bracket positioning and brackettype/design, for use in combined aligner and braces systems and methodsdescribed herein. FIG. 11A show positioning of a bracket on a tooth(e.g., molar) for braces-only treatment, with FIG. 11B showing alternateor modified positioning of the bracket in a combined aligner and bracessystem. FIG. 11C shows selection of a lower profile or wire clip typebracket with no inclination (e.g., a 2-dimensional bracket), and bracketpositioning on the tooth.

Thus, in some embodiments, designing a system for combined aligner andbraces treatment may include selection or modification of a component ofthe braces, such as bracket or wire selection. With regard to brackets,brackets may be selected or shaped specifically to accommodate or evenenhance/optimize treatment when used in combination with an alignersystem. In other words, the bracket design is specific to address one ormore particular weaknesses of the aligner design and the aligner designbolsters the weaknesses of the bracket design. For example, a lowerincisor bracket can be designed such that it can be positioned moregingivally to avoid the lingual surfaces of the upper incisors duringbite closure, but remain efficient for rotations because of the alignercomponent which engages the bracketed teeth in the incisal portion whererotational forces are more efficient to administer due to the greatermesial-distal width (in comparison to the incisor width near thegingiva). This removal of duplication efforts between the two componentscan allow for better appliance esthetics and patient comfort than usinga combined off-the-shelf approach. A bracket may include a shapeselected or designed to accommodate placement of an aligner on thepatient's teeth and/or interaction between the bracket and the aligner.Brackets can be selected with one or more surfaces that contact or evenengage a surface of an aligner. In one example, use of a combinedaligner/braces system may allow selection of certain bracketshapes/designs that might not otherwise be available for a particulartreatment or tooth movement. For example, certain low profile brackets,brackets having a simplified shape, flattened brackets, lingualbrackets, so-called 2-dimensional brackets (such as those commerciallyavailable, e.g., from Forestadent, GmbH), may be selected for use in acombined aligner/braces system as described herein to accomplish toothmovements or treatments that may not otherwise be available or practicalwhen using the same types of brackets in a braces treatment systemalone. Bracket geometry may also be reduced to resemble an alignerattachment, such that it becomes a bracket-attachment hybrid (anattachment with a tube designed to engage an archwire for example).Additionally, particular brackets, such as those mentioned above, may beselected to reduce reduced contact or unwanted interference/contactbetween a bracket and an aligner surface.

Similar to bracket selection, other orthodontic device components (e.g.,archwires, elastics) may be selected based on use of a combinedaligner/braces system. For example, a particular archwire (e.g., size,shape, material properties, etc.) may be selected for use in a combinedsystem where that archwire might otherwise be less desirable for aparticular treatment or movement when using braces alone. For example,the doctor may be able to remain in a super-elastic nickel-titaniumarchwire for a longer period of time before switching to stainlesssteel, or remain in a more comfortable smaller dimension archwire longerbefore stepping up to a thicker wire.

In addition to some potential benefits alluded to above, a combinedaligner and braces system as disclosed herein may advantageously reduceor limit contact between braces components, the teeth, and soft tissues(e.g., the tongue, cheeks, lips) of the patients mouth. For lingualbracket systems, for example, an aligner in a combined system may atleast partially cover the brackets and/or reduce irritating contactbetween the patients tongue and one or more brackets positioned on theteeth. In another example, the sharp portions of the brackets such asthe hooks may be covered by the aligner or even relegated completely tothe design of the aligner itself (i.e, the hooks are in the aligner notin the bracket).

As described herein, an aligner can be shaped to accommodate variouscomponents of an orthodontic braces structure, including brackets aswell as wires and elastics. In traditional orthodontics, a wireretention structure around the braces may be implemented once teeth havemoved to a desired position in order to retain the teeth in position fora selected time. In one embodiment, an aligner is shaped to accommodate,or even replace, a retention structure, such as a wire retentionstructure (e.g., ligature wire structure). FIG. 12 shows an alignershaped to accommodate a retention wire structure on a section of apatient's teeth. In one embodiment, an aligner can be designed to holdthe teeth in the desired position following prior movements, and canwork in conjunction with a wire retention structure or may be designedto allow the aligner to provide the retention structure alone, therebyallowing removal of the wire retention structure—or replacement of thewire retention structure with an aligner shaped to retain teeth in thedesired position. For example, an aligner can be shaped to receive thebracket-positioned teeth and hold the bracketed teeth firmly in place,preventing movement of the teeth or relapse. In such an example, thebraces may be left on the teeth without the wire, in case additionaltooth movement with a wire is required, but the wire is not needed withligature wire (for hygiene benefits) because the aligner portion willhold the bracketed teeth in the desired position.

As described above, braces or bracketed teeth will span two or moreteeth, and may include two or more bracketed teeth adjacent to eachother, as well as one or more unbracketed teeth positioned betweenbracketed teeth. In some instances, braces may be affixed to a sectionof two or more teeth where the section includes one or more teeth nothaving braces/brackets affixed thereto. Such an arrangement may beselected, for example, where one or more teeth within a section of teethare positioned in a manner where positioning of a bracket is eitherundesirable or not practical/possible. This may be the case whenrestored surfaces such as composite, metal or porcelain are present,which can be difficult to bond brackets to, but tooth movement of thetooth/teeth in between is desired. Thus, in one embodiment, a system caninclude an aligner shaped to accommodate one or more teeth positionedbetween two braces or bracketed teeth. The aligner can be designed orshaped so as to elicit movement to said unbracketed tooth/teeth whileaccommodating movement to the adjacent bracketed teeth with a bracesappliance. An example of a longer span in this situation would be themovement of anterior teeth restored with porcelain veneers where bondingbrackets to the veneered teeth risks damage to the veneers upon removalof the braces.

Referring to FIG. 13A, a section of teeth is shown including at leastone tooth positioned between two teeth having brackets attached thereto.In one example, movement of the middle tooth may be desired even thoughplacement of a bracket on that tooth is impractical due to relativepositioning of the teeth (e.g., severe crowding leading to a tooth beingblocked from access for bracket bonding), desired movement that might beimpeded by the thickness of a bonded bracket, or the like. FIG. 13Bshows an aligner positioned on a patient's teeth, with a portion of thealigner receiving the teeth of the section. The aligner may be shaped toelicit movement of the middle tooth or unbracketed tooth as well asaccommodate braces positioned on the adjacent teeth. Arrows show examplemovement or force vectors applied to teeth in the section. Movement ofthe teeth in one phase of treatment as shown may be followed by use ofbraces over the entire section of the teeth (e.g., once movement of theteeth has sufficiently occurred so as to permit the placement of abracket on the middle tooth and/or the practical use of braces on allteeth in the section).

As indicated above, the aligners as described herein can be employedindividually or as a component of an orthodontic treatment including anumber of aligners, appliances, as well as a number of treatment stagesor phases. The aligners can be applied to one arch or both. Theincrement of time in movement between any two positions may include anintermediate position which is a detour and not along the direct pathtowards the final, if the position is to move a tooth in a non-linearmanner (i.e., with a deviation from the most direct path towards thefinal). Thus, as illustrated with reference to FIG. 14, orthodontictreatment may include a number of treatment stages of phases, and mayinclude a number of different movement paths. A phase of treatment mayinclude one or more aligners with a given movement path, such as aplurality of aligners including a particular movement path volume orgeometry to accommodate movement of a bracketed tooth or teeth.

It is understood that the examples and embodiments described herein arefor illustrative purposes and that various modifications or changes inlight thereof will be suggested to persons skilled in the art and are tobe included within the spirit and purview of this application and thescope of the appended claims. Numerous different combinations arepossible, and such combinations are considered to be part of the presentinvention. Any stated advantages herein will be recognized asnon-limiting and/or optional advantages depending at least partially onthe selected design or use according to structures and methods describedherein.

What is claimed is:
 1. A system for treating a patient having at leastone bracketed tooth coupled to at least one bracket of a wire andbracket appliance, the system comprising: a computer comprisinginstructions that, when executed, cause the computer to: receive a firstposition of the at least one bracketed tooth in a treatment plan;receive a second position of the at least one bracketed tooth in thetreatment plan different from the first position; determine a movementpath geometry comprising a volume accommodating mesial-distal movementrelative to an appliance shell of the at least one bracketed toothbetween the first position and the second position, the mesial-distalmovement being elicited by force applied by the wire and bracketappliance; and generate a shell appliance geometry comprising aplurality of teeth receiving cavities shaped according to the first andsecond positions to receive and resiliently position teeth of thepatient and a relief portion comprising a cavity defining a geometricvolume encompassing at least a volume corresponding to a geometricsummation of volumes occupied by the at least one bracketed tooth whenfollowing between the first position and the second position.
 2. Thesystem of claim 1, wherein the at least one bracket is disposed at leastpartially outside the relief portion when the at least one bracketedtooth is received within the cavity.
 3. The system of claim 1, whereinthe relief portion defines an unobstructed insertion path for the atleast one bracket when the appliance shell is at least one of:positioned on the patient's teeth or removed from the patient's teeth.4. The system of claim 3, wherein the relief portion comprises ashortened shell wall extending less than an entire distance between anocclusal portion of the at least one bracketed tooth and a gingival lineof the at least one bracketed tooth when the at least one bracketedtooth is received within the cavity so as to provide the unobstructedinsertion path for the at least one bracket.
 5. The system of claim 4,wherein the shortened shell wall extends partially over the at least onebracket when the at least one bracketed tooth is received within thecavity.
 6. The system of claim 3, wherein the relief portion comprises acutout extending around the at least one bracket when the at least onebracketed tooth is received within the cavity so as to provide theunobstructed insertion path for the at least one bracket.
 7. The systemof claim 1, wherein the volume is defined by the at least one bracketedtooth moving between a plurality of intermediate positions between thefirst position and the second position.
 8. The system of claim 1,wherein the relief portion is shaped to restrict at least one directionof movement of the at least one bracketed tooth during the mesial-distalmovement of the at least one bracketed tooth between the first positionand the second position.
 9. The system of claim 1, wherein the reliefportion comprises an active portion that contacts the at least onebracketed tooth so as to apply a force to the at least one bracketedtooth.
 10. The system of claim 1, wherein the relief portion is shapedto accommodate a plurality of bracketed teeth each coupled to arespective bracket of the wire and bracket appliance.
 11. A system fortreating a patient having at least one bracketed tooth coupled to atleast one bracket of a wire and bracket appliance, the systemcomprising: a computer comprising instructions that, when executed,cause the computer to: receive a first position of the at least onebracketed tooth in a treatment plan; receive a second position of the atleast one bracketed tooth in the treatment plan different from the firstposition; determine a movement path geometry comprising a volumeaccommodating mesial-distal movement of the at least one bracketed toothbetween the first position and the second position, the mesial-distalmovement being elicited by force applied by the wire and bracketappliance; and a shell appliance comprising a plurality of teethreceiving cavities shaped according to the first and second positions toreceive and resiliently position teeth of the patient and a reliefportion comprising a cavity defining a geometric volume encompassing atleast a volume corresponding to a geometric summation of volumesoccupied by the at least one bracketed tooth when following between thefirst position and the second position.
 12. The system of claim 11,wherein the at least one bracket is disposed at least partially outsidethe relief portion when the at least one bracketed tooth is receivedwithin the cavity.
 13. The system of claim 11, wherein the reliefportion defines an unobstructed insertion path for the at least onebracket when an appliance shell is at least one of: positioned on thepatient's teeth or removed from the patient's teeth.
 14. The system ofclaim 13, wherein the relief portion comprises a shortened shell wallextending less than an entire distance between an occlusal portion ofthe at least one bracketed tooth and a gingival line of the at least onebracketed tooth when the at least one bracketed tooth is received withinthe cavity so as to provide the unobstructed insertion path for the atleast one bracket.
 15. The system of claim 14, wherein the shortenedshell wall extends partially over the at least one bracket when the atleast one bracketed tooth is received within the cavity.
 16. The systemof claim 13, wherein the relief portion comprises a cutout extendingaround the at least one bracket when the at least one bracketed tooth isreceived within the cavity so as to provide the unobstructed insertionpath for the at least one bracket.
 17. The system of claim 11, whereinthe volume is defined by the at least one bracketed tooth moving betweena plurality of intermediate positions between the first position and thesecond position.
 18. The system of claim 11, wherein the relief portionis shaped to restrict at least one direction of movement of the at leastone bracketed tooth during the mesial-distal movement of the at leastone bracketed tooth between the first position and the second position.19. The system of claim 11, wherein the relief portion comprises anactive portion that contacts the at least one bracketed tooth so as toapply a force to the at least one bracketed tooth.
 20. The system ofclaim 11, wherein the relief portion is shaped to accommodate aplurality of bracketed teeth each coupled to a respective bracket of thewire and bracket appliance.